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REQUEST FOR TENANCY APPROVAL (RFTA) PACKETFORMS THAT ARE DROPPED OFF, MAILED, AND/OR FAXED WILL NOT BE ACCEPTED!Forms are ONLY ACCEPTED IN PERSON during regular walk-in appointment hours which are:MONDAY1 to 4 pmORWEDNESDAY8:30 to 11:30 am1 to 4 pmPlease complete the attached documents and bring the following requireddocumentation. If documents are not completed and required documentation is notaccompanied with this packet, the RFTA will not be accepted.- Proof of income for ALL household members including but not limited to:FIVE (5) most recent and consecutive check stubs from current employerEmployer contact information including name, address and phone numberCurrent Award Letter for Pension, Social Security, SSI, TANF, etc.Documentation for Child Support Payments- Forms must be completed and signed by both Landlord and TenantCompleted Request for Tenancy Approval (RFTA HUD-52517)Rent Reasonableness Assessment Data SheetTenancy Addendum (HUD-62641)Lead Based Paint DisclosureCarbon Monoxide and Smoke Detector AgreementCertification of Household Income- Forms must be completed and signed by both Landlord and TenantBlank copy of Landlords Lease Agreement & Addendums for the propertyNOTICE: Any changes to the originally submitted lease and/or addendum must be pre-approved by SHAprior to execution of the lease or lease may NOT be approvedREMEMBER THAT ALL INCOME MUST BE REPORTED!FAILURE TO PROVIDE INCOME OR REQUIRED DOCUMENTS WILL DELAY PROCESSING.November 2019/cc-g
Request for Tenancy ApprovalU.S Department of Housing andUrban DevelopmentHousing Choice Voucher ProgramOffice of Public and Indian HousingOMB Approval No. 2577-0169exp. 7/31/2022The public reporting burden for this information collection is estimated to be 30 minutes, including the time for reviewinginstructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing thecollection of information. The Department of Housing and Urban Development (HUD) is authorized to collect the informationon this form by Section 8 of the U.S. Housing Act (42 U.S.C. 1437f). Form is only valid if it includes an OMB Control Number.HUD is committed to protecting the privacy of individuals’ information stored electronically or in paper form, in accordancewith federal privacy laws, guidance, and best practices. HUD expects its third-party business partners, including PublicHousing Authorities, who collect, use maintain, or disseminate HUD information to protect the privacy of that information inAccordance with applicable law.When the participant selects a unit, the owner of the unit completes this form to provide the PHA with information about theunit. The information is used to determine if the unit is eligible for rental assistance. HUD will not disclose this informationexcept when required by law for civil, criminal, or regulatory investigations and prosecutions.1. Name of Public Housing Agency (PHA)2. Address of Unit (street address, unit #, city, state, zip code)Springfield (IL) Housing Authority3. Requested Lease Start4. Number of Bedrooms 5. Year Constructed6. Proposed Rent 7. Security DepositDate9. Structure8. Date Unit AvailableAmtType10. Single Family Detached (one family under one roof) Semi-Detached (duplex, attached on one side) Rowhouse/Townhouse (attached on two sides) Low-rise apartment building (4 stories or fewer) High-rise apartment building (5 stories) Manufactured Home (mobile home)for InspectionIf this unit is subsidized, indicate type of subsidy: Section 202 Section 221(d)(3)(BMIR) Tax Credit HOME Section 236 (insured or uninsured) Section 515 Rural Development Other(Describe Other Subsidy, including any stateor local subsidy)Utilities and AppliancesThe owner shall provide or pay for the utilities/appliances indicated below by an “O”. The tenant shall provide or pay for theutilities/appliances indicated below by a “T”. Unless otherwise specified below, the owner shall pay for all utilities and provide therefrigerator and range/microwave.ItemSpecify fuel typePaid by11.HeatingCookingWater Heating Natural gas Bottled gas Electric Heat Pump Oil Other Natural gas Bottled gas Electric Other Natural gas Bottled gas Electric Oil OtherOther ElectricWaterSewerTrash CollectionAir ConditioningOther (specify)Provided byRefrigeratorRange/MicrowavePrevious editions are obsolete1HUD-52517 (7/2019)
12. Owner’s Certificationsc. Check one of the following:a. The program regulation requires the PHA to certify thatLead-based paint disclosure requirements do not applythe rent charged to the housing choice voucher tenantbecause this property was built on or after January 1,is not more than the rent charged for other unassisted1978.comparable units. Owners of projects with more than 4units must complete the following section for mostThe unit, common areas servicing the unit, and exteriorrecently leased comparable unassisted units within thepainted surfaces associated with such unit or commonpremises.areas have been found to be lead-based paint free by aAddress and unit number Date Rented Rental Amountlead-based paint inspector certified under the Federal1.certification program or under a federally accreditedState certification program.2.A completed statement is attached containing3.disclosure of known information on lead-based paintand/or lead-based paint hazards in the unit, commonb. The owner (including a principal or other interestedareas or exterior painted surfaces, including aparty) is not the parent, child, grandparent, grandchild,statement that the owner has provided the lead hazardsister or brother of any member of the family, unlessinformation pamphlet to the family.the PHA has determined (and has notified the owner13. The PHA has not screened the family’s behavior orand the family of such determination) that approvingsuitability for tenancy. Such screening is the owner’sleasing of the unit, notwithstanding such relationship,responsibility.would provide reasonable accommodation for a family 14. The owner’s lease must include word-for-word allmember who is a person with disabilities.provisions of the HUD tenancy addendum.15. The PHA will arrange for inspection of the unit and willnotify the owner and family if the unit is not approved. Print or Type Name of Owner/Owner RepresentativePrint or Type Name of Household HeadOwner/Owner Representative SignatureHead of Household SignatureBusiness AddressPresent AddressTelephone NumberPrevious editions are obsoleteDate (mm/dd/yyyy)Telephone Number2Date (mm/dd/yyyy)HUD-52517 (7/2019)
SHA RENT REASONABLENESS ASSESSMENT DATA SHEETSHA is required to assess whether the proposed rent for your unit is comparable to similar units within its local market. SHA's RentReasonable assessment is based on the information you provide on this sheet. Your signature below certifies that the statements made onthis form are true and correct. If the SHA Inspector is unable to verify the information provided, SHA will need to re-assess the proposed rentand may need to request that it be lowered, which will delay the processing of your contract approval.Tenant Name:Address:Apartment #:City:About The Unit:Requested Rent: Number of Bedrooms:Square Footage:Unit Age:Number of Full Baths:Half Baths:Building Type: Single FamilyUnit Condition: Excellent Semi-Detached Duplex Row House Townhouse Good FairUnit Size: Large MediumUtilities Included: ElectricZip: Gas Manufactured/Mobile HomeBuilt: Garden/Walk-Up High Rise Poor Small Water Sewer Garbage Other Electric Water Heating A/CProperty Amenities: Basement Business/Fitness Center Cable/Internet Ready Carpeting Ceiling Fans Central A/C Ceramic Tile Floors Clubhouse Covered/Off-Street Parking Deck/Balcony/Patio/Porch Dishwasher Elevator Energy Efficient Cert Unit Fenced Garage Garbage Disposal Handicap Accessible Hardwood Floors Laundry Facilities Modern Appliances Playground/Courts Pool Range Refrigerator Security System Storage Washer/Dryer Hook-up Wall/Window A/C Working Fireplace Yard Sprinkler System Other Amenities:Housing Services: Yes (Ex: receive packages for tenants, free basic cable/Wi-Fi, lawn upkeep/snow removal)Maintenance: On-SiteLandlord Signature: No Off-SiteDate://Date://Landlord Printed Name:Section 8 Inspector Signature:WARNING: Title 18, US Code Section 1001, states that a person who knowingly and willingly makes false or fraudulent statements to any Department orAgency of the United States is guilty of a felony. State law may also provide penalties for false or fraudulent statements.(June 2018/cc-g)
b.regulation, as a condition for Federal assistance tothe tenant and tenant’s family under the Section 8voucher program.In case of any conflict between the provisions of thetenancy addendum as required by HUD, and anyother provisions of the lease or any other agreementbetween the owner and the tenant, the requirementsof the HUD-required tenancy addendum shallcontrol.Housing quality standards (HQS). The HUD minimum qualitystandards for housing assisted under the Section 8 tenant-basedprograms.HUD. The U.S. Department of Housing and Urban Development.HUD requirements. HUD requirements for the Section 8 program.HUD requirements are issued by HUD headquarters, as regulations,Federal Register notices or other binding program directives.Lease. The written agreement between the owner and the tenant forthe lease of the contract unit to the tenant. The lease includes thetenancy addendum prescribed by HUD.PHA. Public Housing Agency.Premises. The building or complex in which the contract unitis located, including common areas and grounds.Program. The Section 8 housing choice voucher program.Rent to owner. The total monthly rent payable to the owner for thecontract unit. The rent to owner is the sum of the portion of rentpayable by the tenant plus the PHA housing assistance payment to theowner.Section 8. Section 8 of the United States Housing Act of 1937 (42United States Code 1437f).Tenant. The family member (or members) who leases the unit fromthe owner.Voucher program. The Section 8 housing choice voucher program.Under this program, HUD provides funds to a PHA for rent subsidyon behalf of eligible families. The tenancy under the lease will beassisted with rent subsidy for a tenancy under the voucher program.18. Changes in Lease or Renta.b.c.d.The tenant and the owner may not make any changein the tenancy addendum. However, if the tenant andthe owner agree to any other changes in the lease,such changes must be in writing, and the ownermust immediately give the PHA a copy of suchchanges. The lease, including any changes, must bein accordance with the requirements of the tenancyaddendum.In the following cases, tenant-based assistance shallnot be continued unless the PHA has approved anew tenancy in accordance with programrequirements and has executed a new HAP contractwith the owner:(1)If there are any changes in leaserequirements governing tenant or ownerresponsibilities for utilities or appliances;(2)If there are any changes in lease provisionsgoverning the term of the lease;(3)If the family moves to a new unit, even ifthe unit is in the same building or complex.PHA approval of the tenancy, and execution of anew HAP contract, are not required for agreedchanges in the lease other than as specified inparagraph b.The owner must notify the PHA of any changes inthe amount of the rent to owner at least sixty daysbefore any such changes go into effect, and theamount of the rent to owner following any suchagreed change may not exceed the reasonable rentfor the unit as most recently determined orredetermined by the PHA in accordance with HUDrequirements.19. NoticesAny notice under the lease by the tenant to the owner or by the ownerto the tenant must be in writing.20. DefinitionsContract unit. The housing unit rented by the tenant with assistanceunder the program.Family. The persons who may reside in the unit with assistance underthe program.HAP contract. The housing assistance payments contract between thePHA and the owner. The PHA pays housing assistance payments tothe owner in accordance with the HAP contract.Household. The persons who may reside in the contract unit. Thehousehold consists of the family and any PHA-approved live-in aide.(A live-in aide is a person who resides in the unit to provide necessarysupportive services for a member of the family who is a person withdisabilities.)Previous editions are obsoletePage 13 of 13form HUD-52641 (7/2019)
Disclosure of Information on Lead-Based Paint and/or Lead-Based Paint HazardsLead Warning StatementHousing built before 1978 may contain lead-based paint. Lead from paint, paint chips, and dust can pose health hazards if notmanaged properly. Lead exposure is especially harmful to young children and pregnant women. Before renting pre-1978 housing,lessors must disclose the presence of known lead-based paint and/or lead-based paint hazards in the dwelling. Lessees must alsoreceive a federally approved pamphlet on lead poisoning prevention.Lessor's Disclosure(a) Presence of lead-based paint and/or lead-based paint hazards (check (i) or (ii) below):(i)Known lead-based paint and/or lead-based paint hazards are present in the housing.Explain:(ii)Lessor has no knowledge of lead-based paint and/or lead-based paint hazards in the house(b) Records and reports available to the lessor (check (i) or (ii) below):(i)Lessor has provided the lessee with all available records and reports pertaining to leadbased paint and/or lead-based paint hazards in the housing (list documents below).Explain:(ii)Lessor has no reports or records pertaining to lead-based paint and/or lead-based painthazards in the housing.Lessee's Acknowledgment (initial)(c)Lessee has received copies of all information listed above.(d)Lessee has received the pamphlet Protect Your Family from Lead in Your Home.Agents Acknowledgment (initial)(e)Agent has informed the lessor of their obligations under 42 USC. 4852(d) and is aware of his/her responsibilityto ensure compliance.Certification of AccuracyThe following parties have reviewed the information above and certify, to the best of their knowledge, that the information theyhave provided is true and gentDateAgentDate
CARBON MONOXIDE ALARM & SMOKE DETECTOR AGREEMENTResident Name:Address/Unit:State law requires property owners to install one approved operating carbon monoxide alarm within 15 feet ofevery sleeping room in a dwelling only if the building uses fossil fuel combustion for any purpose or has anattached garage. State law also requires one smoke detector within 15 feet of each sleeping room. Thesedevices may be combined or separate and can be battery operated, plug-in with battery back-up, or hard-wiredwith battery backup.It is the responsibility of the property owner to supply and install the required alarms, and provide writteninstructions regarding testing, operation, and maintenance to the resident.It is the responsibility of the resident to regularly test the alarms, provide general maintenance for the alarms,including replacement of batteries as necessary, and to notify the owner in writing of any deficiencies that thetenant cannot correct. Tampering with, removing, destroying, disconnecting, or removing the batteries from anyinstalled alarm is a Class 4 Misdemeanor for a first conviction, and a Class 4 Felony for any subsequentconvictions.Resident shall read and initial each item:1.No carbon monoxide alarms are required in this dwelling (Skip to #3)2.Number ofCarbon Monoxide Alarm(s) are installed and workingI have received written instructions for the carbon monoxide alarm3.Number ofSmoke Detector Alarm(s) are installed and workingI have received written instructions for the smoke detectors4.I understand testing, operation & maintenance of these devices5.I will notify the owner in writing of any operating deficiencies of these devicesI have read, understand, acknowledge and agree to the above:Head of Household SignatureOwner Representative SignaturePrint Name & DatePrint Name & Date
CERTIFICATION OF FAMILY INCOMEINSTRUCTIONS:Any sources of income identified in this interview must be promptly verified and an interim reexamination must be processed according toSHA procedures. The Housing Specialist must also initiate action against the household for any violation of program rules revealed during thisinterview. When completed, all adults over the age of 18 in the household and the Housing Specialist must sign this certification in the spacesprovided.INTERVIEW QUESTIONS:1. Is any household member employed either full-time, part-time or seasonally?YesNo2. Does any household member expect to work for any period during the next twelve months?YesNo3. Does any household member work for someone who pays them in cash?YesNo4. Is any household member on leave of absence due to lay-off, medical, maternity or military leave?YesNo5. Does any household member now receive or expect to receive unemployment benefits?YesNo6. Does any household member now receive or expect to receive child support?YesNo7. Is any household member entitled to child support that they are not receiving?YesNo8. Does any member of your household now receive or expect to receive alimony payments?YesNo9. Is any household member entitled to alimony payment that they are not receiving?YesNo10. Does any household member receive or expect to receive public aid assistance?a.SNAP BenefitsYesNob.TANF CashYesNo11. Does any household member receive or expect to receive Social Security benefits?YesNo12. Does any household member receive or expect to receive income from retirement, pension or annuity?YesNo13. Does any household member receive regular contributions of cash and/or gifts from outside the home?a.IndividualsYesNob.AgenciesYesNo14. Does any household member receive income from assets including interest from?a.Checking or Savings AccountYesNob.Stocks or BondsYesNoc.Income from Rental PropertyYesNo
INTERVIEW QUESTIONS CONTINUED:YESNO15. Have you applied for all benefits you may be entitled to including general assistance?16. Do you need assistance in applying for or obtaining benefits?17. Is there anyone staying with you in your unit without approval?18. Who pays for your utilities?19. What funds do you use to pay for food and clothing?20 What funds do you use to pay for personal items like toiletries, cigarettes, school supplies, etc?21. What form of transportation do you use and how is it paid for?CERTIFICATIONS:I certify that I have answered all the above questions fully and truthfully to the best of my knowledge. I understand my reportingrequirements and understand that failure to report all household income is a Federal Offense punishable by fines and imprisonment.Head of Household SignatureDateSpouseDateOther Adult over 18 years of ageDateOther Adult over 18 years of ageDateOther Adult over 18 years of ageDate//////////SUMMARY TO BE COMPLETED BY HOUSING CHOICE VOUCHER SPECIALIST:Based upon answers to this certification, it has been determined that this applicant/participant doeshousehold funds which are considered income.or does nothaveI certify that I have asked any question desirable to any answers the applicant/participant gave regarding this questionnaire and will promptlytake action as described above./Housing Choice Voucher Specialist SignatureDate/
Employer contact information including name, address and phone number Current Award Letter for Pension, Social Security, SSI, TANF, etc. Documentation for Child Support Payments -Forms must be completed and signed by both Landlord and Tenant Completed Request for Tenancy Approval (RFTA HUD-52517) Rent Reasonableness Assessment Data Sheet
